HIPAA Security Rule risk analysis
RiskRequired, accurate, thorough — covers all ePHI flows (Cloud + on-prem + endpoint + BAAs). Output: documented risks + likelihood + impact.
Reference
§164.308(a)(1)(ii)(A)
Evidence
Risk analysis report
Risk management plan update
RiskAddress risks identified — implement, mitigate, accept; track residual risk.
Reference
§164.308(a)(1)(ii)(B)
Evidence
Risk management plan
Workforce HIPAA training
WorkforceRequired for every workforce member — Privacy + Security awareness; new hires within reasonable time; updated when material change.
Reference
§164.530(b), §164.308(a)(5)
Owner
Privacy officer + HR
Evidence
Training completion records
Policies + procedures review
PoliciesEvery Security + Privacy Rule policy reviewed and updated as needed. 6-year retention required.
Owner
Privacy + Security officers
Evidence
Updated policy library
BAA inventory + renewal review
BAAEvery Business Associate has a current, valid BAA covering PHI use + breach notification. Refresh expiring agreements.
Reference
§164.308(b), §164.502(e)
Owner
Privacy officer + Legal
Evidence
BAA register + renewals
Notice of Privacy Practices review
PrivacyNPP must be current; redistribute on material change; available on website + at point of care.
Evidence
NPP version + posting evidence
Periodic technical + nontechnical evaluation
EvaluationRequired §164.308(a)(8) — confirm policies + procedures continue to meet the Security Rule. Often combined with annual risk analysis.
Evidence
Evaluation report